The UN Urbanization Prospects reported that 54% of people in the world lived in urban areas in 2016 with a projected increase to over 55% of the world population in 2018. By 2050, the proportion of the world’s urban population is projected to increase to about 68%, with the greatest increase occurring in Asia and Africa where 88% of all new urban inhabitants will reside.
Between 2018 and 2050, the urban population in less developed regions is projected to increase by 72% compared to 13% for more developed regions. This increase in urban populations is largely due to natural population growth trends, migration from rural areas, reclassification of rural areas, and increase of urban informal settlements.
Rapid urbanization and a lack of political responses by national and municipal governments are contributing to the persistence of urban poverty, slums or informal settlements, and health inequities in cites including the increasing share of the poor living in urban areas (Map below) has outpaced services and infrastructure provision.
Individual demographic characteristics such as age, gender, and socioeconomic status have also been linked to poor physical health in informal settlements, and stress has been cited as a factor associated with poor mental health outcomes in these settlements.
Residents of informal settlements are also economically vulnerable during any COVID-19 responses. Any responses to COVID-19 that do not recognize these realities will further jeopardize the survival of large segments of the urban population globally. Most top-down strategies to arrest an infectious disease will likely ignore the often-robust social groups and knowledge that already exist in many slums. Space constraints, violence and over-crowding in slums makes physical distancing and self-quarantine impractical, and the rapid spread of an infection highly likely.
Among cities in sub-Saharan Africa with a million or more population, between 50 and 80% of the urban population lives in informal settlements, UN Habitat noted. While urbanization can be beneficial for health, the increase in urban informal settlements represents a significant challenge for promoting more sustainable and healthy cities in the global south, since informal settlements are also the location of persistent health inequities.
In East Africa and the Horn of Africa, countries already struggling to meet the needs of their people found themselves coping with large numbers of people fleeing from elsewhere with an increasing proportion settling in towns and cities. Regular hand washing is problematic when there is a lack of access to water or adequate sanitation. Overcrowding and poor housing mean that staying at home and away from others is almost impossible. Testing can be a challenge due to a lack of resources and capacity.
In its draft 2020 Budget Policy Statement (BPS), the Treasury noted that 10 million Kenyans live in slums, which translates to 21.2 percent of the 47 million population as at least in 2019 census [Chart above]. Nairobi leads with 36 percent (8 million) of its population living in slums.
Forces contributing to existing urban health inequities
As a consequence, the African Population and Health Research Center (APHRC) set out in the year 2000 to develop and implement a portfolio of research programs aimed at understanding population dynamics, and health and socioeconomic challenges in the context of rapid urbanization in Nairobi City. In 2000, cross-sectional slum survey was conducted in Nairobi’s slum areas.
The survey results showed that slum residents have the worst health and socio-economic outcomes out of any social group in Kenya, with limited access to education, employment, water and sanitation. Slum residents were found to be more likely to be exposed to violence and social unrest. The survey report also revealed the existence of an environment devoid of the presence of the public sector and law enforcement agencies, while contending with the reality that residents had no legal land entitlements.
Most importantly, intra-urban inequities were masked by national indicators that treated all urban residents as a homogeneous group. As such, it was highly unlikely that urban planning would take into account slum or slum-like vulnerabilities. These findings highlighted the need for a focused surveillance of Nairobi’s slum residents in order to better understand the consequences of rapid urbanization and its inter-linkages with observed health and socioeconomic outcomes.
Informing appropriate and effective health promotion interventions with an equitable approach to arresting the COVID-19 pandemic must change standard ways of treating the urban poor, create more participatory governance, improve the delivery of essential services including health care, and invest new resources to ensure urban informal settlements benefit in the long term.
Relationship between poor slum infrastructure, social, economic and human rights for women and girls
The 2014 Kenyan National Slum Upgrading and Prevention Policy defines a slum as ‘a human settlement characterized by dilapidated housing structures, overcrowding, abject poverty and unemployment, high insecurity incidences, insecure land tenure, exclusion of physical development, inadequate infrastructural services and often located in an unsustainable environment’:
- Durable housing of a permanent nature that protects against extreme climate conditions.
- Sufficient living space which means not more than three people sharing the same room.
- Easy access to safe water in sufficient amounts at an affordable price.
- Access to adequate sanitation in the form of a private or public toilet shared by a reasonable number of people.
- Security of tenure that prevents forced evictions.
On the one hand, the challenge of urban slums is particularly acute in Kenya and its capital city Nairobi, where over 65% of the capital’s almost 3.2 million people live in informal settlements occupying less than 10% of the land area. Slum dwellers in Nairobi experience poorer health than their better off urban counterparts.
For instance, child mortality rate in Nairobi was found to be 62 per 1000 births, but 151 per 1000 in the city’s slums. A case in point are slums such as Kibera or Kinubi meaning a forest or jungle; a division of Nairobi Area, Kenya, and neighbourhood of the city of Nairobi, 6.6 kilometres (4.1 mi) from the city centre is the largest slum in Nairobi, and the largest urban slum in Africa.
In fact, the 2009 Kenya Population and Housing Census report Kibera’s population as 170,070, contrary to previous estimates of one or two million people. Other reports suggest the total Kibera population may be 500,000 to well over 1,000,000 depending on which slums are included in defining Kibera.
Most of Kibera slum residents live in extreme poverty, with an average income is less than $2 a day. Unemployment rates are high. Persons living with HIV in the slum are many, as are AIDS cases. Cases of assault and rape are common. There are few schools, and most people cannot afford education for their children.
Moreover, clean water is scarce. Diseases caused by poor hygiene are prevalent. A great majority living in the slum lack access to basic services, including electricity, running water, and medical care. The pandemic is another obstacle the community must tackle together in Kibera.
Public health officials are quickly realizing that prevention strategies must be adapted to the realities on the ground. Many large African cities have huge day labour, employment sectors; this informal structure means that people have fewer resources to navigate public health emergencies. Self-isolation and quarantining are simply not realistic in a huge settlement with high poverty rates and poor infrastructure.
Meanwhile, Kenyan authorities have initiated steps towards this, and this will unleash through a clearance programme to replace the slum with a residential district of high-rise apartments, and to relocate the residents of these new buildings upon completion. As for the pandemic, locals have taken measures to stop the spread of COVID-19 themselves. As information about prevention emerged in Kibera, the report notes.
In contrast, a January 2020 report, the Treasury noted that the Ministry of Transport, Infrastructure, Housing and Urban Development had so far managed to deliver 228 units. While the delivery of low-cost units would be mostly through a public-private partnership model, with the State providing an enabling environment including tax incentives for developers.
Nevertheless, implementation of the housing programme has been underway since 2018 but delivery of the houses has been underwhelming. The government expects to build about 60,000 while the balance will be financed and constructed by the private sector. Which is against the 500,000 units by 2022 that the Jubilee administration promised in 2017 on re-election, a report discloses.
At the same time, governments have already begun to impose draconian quarantine and physical distancing measures for the urban poor without also ensuring that those residing in urban slums can meet their everyday needs, such as food and clean water. Racism, xenophobia, and stigma against the poor, migrants, and lower classes have also increased during the COVID-19 pandemic.
COVID-19 responses should coordinate strategies to ensure that large percentages of the urban populations in low-income countries no longer have to live in extreme poverty. However, improvement in the living conditions of informal settlements and its residents through titling to enhance tenure security; Infrastructure upgrades for basic services (roads, drainage, water, sanitation, street lighting, community facilities); and livelihoods support and community engagement will assess and address risks, including the impacts of COVID-19.
We hope that funds such as World Bank approved $150 million International Development Association credit to improve tenure security and access to basic services for 1.7 million residents living in selected Kenya’s urban informal settlements will fully implement so as to increase the connectivity of residents to socioeconomic opportunities.